SP7.2.6 Where is the nerve? Review of operation note documentation practice for inguinal hernia repair

Introduction Careful identification and management of inguinal nerves during inguinal hernia repair is important to avoid iatrogenic injury. Documentation of this practice informs postoperative clinical management. We set out to investigate how often surgeons identify inguinal nerves and document findings and management in operation notes. Methods Retrospective review of operation notes at single District General Hospital (DGH). Operation notes analysed for documentation of identification and intraoperative management (preservation vs sacrifice) of the inguinal nerves: iliohypogastric, ilioinguinal and genital branch of genitofemoral nerve. Data including baseline characteristics of each patient, hernia characteristics, and primary operating surgeon ascertained for subgroup analysis. Results A total of 100 patients were included in the analysis. Identification of any of the inguinal nerves (generic - “nerve”) was documented in 17% of operation notes. Documentation of named individual nerves in operation notes was limited. No documentation of intraoperative management of inguinal nerves found in 83% of operation notes. Preservation of the inguinal nerves (generic - “nerve”) was recorded in 8% and sacrifice recorded in 9% of cases. Subgroup analysis revealed similar incidence of documentation of identification and management of inguinal nerves across grades of primary surgeon, with overall incidence low for all grades. Conclusion This study has revealed a lack of appreciation of the importance of documentation of identification and intraoperative management of inguinal nerves in operation notes. Further consideration of the potential implications of poor documentation would be beneficial to improve standards.

Where is the nerve? Review of operation note documentation practice for inguinal hernia repair

Introduction Careful identification and management of inguinal nerves during inguinal hernia repair is important to avoid iatrogenic injury. Documentation of this practice may inform postoperative clinical management. We set out to investigate how often surgeons identify inguinal nerves and document findings and management in their operation notes. Methods We carried out a retrospective review of operation notes at a single district general hospital. We analysed operation notes for documentation of identification and intraoperative management (preservation or sacrifice) of the inguinal nerves (iliohypogastric, ilioinguinal, genital branch of genitofemoral nerve). We collected data on the baseline characteristics of the patients, hernia characteristics and primary operating surgeons for subgroup analysis. Results A total of 100 patients were included in the analysis. Identification of any inguinal nerves (generic ‘nerve’) was documented in 17% of operation notes. Documentation in the operation notes of named individual nerves was limited. No documentation of intraoperative management of inguinal nerves was found in 83% of operation notes. Preservation of the inguinal nerves (generic ‘nerve’) was recorded in 8% and sacrifice recorded in 9% of cases. Subgroup analysis revealed similar incidence of documentation of identification and management of inguinal nerves across grades of primary surgeon, with overall incidence low for all grades. Conclusion This study reveals a lack of appreciation of the importance of documenting identification and management of inguinal nerves in operation notes. Further consideration of the potential implications of poor documentation would be beneficial to improve standards.

A COMPARISON STUDY BETWEEN ULTRASOUND-GUIDED AND CONVENTIONAL (BLIND) ILIOINGUINAL/ ILIOHYPOGASTRIC NERVE AND GENITAL BRANCH OF GENITOFEMORAL NERVE BLOCKS FOR OPEN INGUINAL HERNIA REPAIR.

Background: Inguinal hernia repair is the commonest operation in surgical practice. Now it is also performed under regional nerve blocks by blocking nerves ilioinguinal (II)/iliohypogastric (IH) and genital branch of genital femoral nerve combined with a surgical feild inltration with a long-acting local anaesthetic(LA) agent. LA inltration improves acute postoperative pain management, decreases postoperative visual analogue scale(VAS)scores, opioid demand, and time to rst rescue analgesic administration. Thi Objective: s study was carried out to compare the effect of ultrasound guided ilioinguinal/ iliohypogastric nerve and genital branch of genitofemoral nerve block with conventional (blind) block in terms of success rate, postoperative analgesia and complications. Method: We conducted a prospective randomized controlled studyamongst 100 ASA I-III patients posted electively for open inguinal hernia repair. Various parameters such as age, sex, weight, BMI, vitals like pulse rate, ECG, blood pressure was recorded and Post-Operative VAS at 30minutes, 1hr, 1hr30mins, 2hrs, 2hrs30mins, 3hrs, 3hrs30 minutes and 4hours was noted. Qualitative and quantitative analysis was done. Result: In conventional group 8 (16%) patients amongst 50 (100%) required general anaesthesia in between the surgery even after sedation + analgesia+ propofol whereas in USG group 2 (8%) patients required general anaesthesia. The patient receiving USG guided block had signicantly lower post-operative VAS scores till 2 hours 30 mins as compared to the patient receiving conventional ILN/INH nerve blocks who had higher VAS scores . There Conclusion : by we found that ultrasound guided block for open inguinal hernia repair has signicantly better patient care in comparison with conventional block.

Anatomical Variations in Formation and Branching Pattern of the Border Nerves of Lumbar Region

Background Ilioinguinal, iliohypogastric, and genitofemoral nerves are together known as “border nerves” of the lumbar plexus. Aim of this study was to find out the variations in formation and branching pattern of these nerves and correlate with their clinical relevance. Materials and Methods For this study 30 formaldehyde preserved cadavers were used, and the nerves were studied on both the sides, thus making the sample size of 60. Results Iliohypogastric nerve was absent in 6.6% and double in 1.6%. It was prefixed with a twig from T12 in 6.6% and had origin from both L1 and L2 in 1.6%. The ilioinguinal nerve was absent in 3.3% and double in 3.3%. The genitofemoral nerve exhibited a large number of variations. It was absent in 1.6%. Early division of the nerve prior to emergence from the psoas major muscle was noticed in 13.3%, and early division soon after emergence from the muscle was noted in 3.3%. In one cadaver, on one side, genital branch was absent, and it continued as femoral branch only. In another cadaver, the nerve continued as genital branch only. In two other cases, genital and femoral branches were seen to arise separately from the lumbar plexus. The nerve had its origin from L1 and L2 in 25%, L2 and L3 in 25%, L1 in 3.3%, L2 in 46.66%, and L3 in 1.6% of the cases. Conclusion Knowledge of these variations would be of immense help during surgical approach and giving nerve block for anesthesia and postoperative analgesia in this region.

Two new species of the genus Metaxonchium Coomans & Nair, 1975 (Nematoda, Dorylaimida, Belondiridae) from Vietnam

Two new species of the genus Metaxonchium are described from natural habitats of Vietnam. Metaxonchium bonkowskii sp. n. is characterized by its 1.69–2.23 mm long body, lip region offset by weak constriction and 9.5–10.5 µm broad, odontostyle 11–13 µm long, neck 673–868 µm long with the pharyngeal expansion occupying 66–77% of its length, anterior genital branch reduced to a uterine sac 75–135 µm long or 4–7% of body length, posterior uterus tetrapartite and including a Z–like differentiation, V = 51–55, and female tail short and rounded (37–51 µm, c = 66–97, c’ = 0.5–0.7). Metaxonchium silvaticum sp. n is characterized by its 1.28–1.43 mm long body, lip region offset by weak depression and 7.0 µm broad, odontostyle 8–9 µm long, neck 502–630 µm long with the pharyngeal expansion occupying 65–76% of its length, anterior genital branch reduced to a uterine sac 65–80 µm long or 4–6% of body length, posterior uterus tripartite, non-echinophor, V = 52–57, tail short and rounded (18–23 µm, c = 56–74, c’ = 0.6–0.8) with abundant blister–like or saccate bodies, spicules 41 µm long, and seven spaced ventromedian supplements.

Pulsed Radiofrequency Treatment for Chronic Post-Surgical Orchialgia: A Double-Blind, Sham-Controlled, Randomized Trial: ThreeMonth Results

Background: Chronic post-surgical pain in the groin region represents a challenge for the managing physician and is a burden on the quality of life of the patient. None of the existing interventions or medical treatment is satisfactory. Objectives: We aim to evaluate the analgesic efficacy of pulsed radiofrequency (PRF) applied to the ilioinguinal nerve and the genital branch of the genitofemoral nerve for patients suffering from chronic post-surgical orchialgia. Study Design: A prospective randomized, controlled clinical trial. Settings: An interventional pain unit in a tertiary center at a university hospital in Egypt. Methods: Seventy patients complaining of chronic post-surgical orchialgia were randomized into 2 groups: PRF group (n = 35), received pulsed radiofrequency on the ilioinguinal nerve and genital branch of the genitofemoral nerve, or sham group (n = 35). The percentage of patients that showed > 50 % reduction of their visual analog scale (VAS) pain score as well as the percentage of patients that did not require additional analgesic drugs was assessed. The VAS pain score and the global perceived effect (GPE) were reported during the 3-month follow-up period. Results: The percentage of patients that showed > 50% reduction of their VAS pain score was 80% (24/30) in the PRF group versus 23.33% (7/30) in the sham group. The percentage of patients that did not require analgesic drugs was 50% (15/30) in the PRF group versus 3.3% (1/30) in the sham group. There was a significant reduction of the mean post-procedural VAS pain score at 2, 4, 6, 8, and 12 weeks (P = 0.001) in the PRF group in comparison to the sham group. Likewise, there was a significant improvement of the GPE in the PRF group in comparison to the sham group (P = 0.00). Limitations: The study’s follow-up period was limited to 3 months only. Conclusions: For patients suffering from chronic post-surgical orchialgia, PRF applied to the ilioinguinal nerve and the genital branch of the genitofemoral nerve is an effective treatment modality. It provides long-lasting pain relief and decreases the demand for pain medications. Key words: Orchialgia, groin pain, radiofrequency, ilioinguinal nerve, genitofemoral nerve

A new dagger nematode, Xiphinema poasense n. sp. (Nematoda: Longidoridae), from Costa Rica

A new dagger nematode,Xiphinema poasensen. sp., is described and illustrated from three populations extracted from soil associated with a combined plantation ofEucalyptussp.,Cupressussp. andPennisetumsp. and wild plants from a tropical pre-montane forest in Costa Rica. The new dagger nematode is characterised by a moderate body size 2612 (2416-3042) μm long, a rounded lip region 15.0 (13.5-16.5) μm broad, separated from the body contour by a shallow depression, amphidial fovea large, stirrup-shaped, a very long odontostyle (175 (164-188) μm), stylet guiding ring located 167 (136-181) μm from anterior end, vulva situated anterior to mid-body (36-40%), anterior genital branch complete but strongly reduced, without uterine differentiation, female tail short, hemispherical to convex-conoid with a c′ ratio = 0.7 (0.6-0.8) and bearing two pairs of caudal pores, and male absent. Integrative diagnosis was completed with molecular data using D2-D3 expansion segments of 28S rRNA, ITS1 region, partial 18S-rRNA and the partial mitochondrial gene cytochrome c oxidase subunit 1 (coxI). The phylogenetic relationships based on D2-D3 segments of this species with otherXiphinemaspp. of theX.non-americanumgroup indicated thatX. poasensen. sp. clustered with other species with a reduced anterior genital branch from the morphospecies Group 2,viz.,X. costaricenseandX. krugi. However, the phylogeny ofcoxIand partial 18S rRNA gene revealed that the new species did not cluster withXiphinemaspecies having the anterior genital branch absent or reduced (i.e., morphospecies Groups 1 and 2, respectively).

Metaxonchium toroense n. sp. (Nematoda, Dorylaimida, Belondiridae) from Costa Rica, with the first molecular study of a representative of the genus

The new species Metaxonchium toroense n. sp. from natural habitats of Costa Rica is described, including light microscopy (LM), scanning electron microscopy (SEM) and molecular (D2–D3 28S rDNA) analyses. The new species is characterized by its general size, the dimensions and appearance of its lip region, the length of the odontostyle and its fusiform aspect, the length of the neck and its pharyngeal expansion, the reduction of the anterior genital branch to a very short uterine sac without any rudiment of ovary or oviduct, tripartite and non-echinophor posterior uterus, the somewhat posterior vulva position, the length and shape of the caudal region, and the absence of males. Molecular analyses, the first to be performed on a Metaxonchium species, show a close relationship of the new species with representatives of the genera Axonchoides and Syncheilaxonchium.